Addressing Disparities in Outcomes of Screening for Colorectal Cancer in Community-Based Settings

项目总结/摘要：结直肠癌（CRC）是美国癌症死亡的第二大原因。 美国，尽管总体CRC死亡率一直在下降，但差异仍然存在， 特别是对黑人和美洲原住民来说。CRC筛查非常有效， 国家重视改善社会弱势群体接受筛查的机会。但 筛查的益处取决于接受高质量的检测和在异常时及时的后续护理。 因此，即使不同人群的筛查参与率相似，差异也可能持续存在。 最近，美国预防服务工作组强调了在理解CRC差异方面的差距， 相对缺乏已证明可消除种族和族裔差异的干预措施。目标 本申请的目的是通过阐明 在整个筛查过程中，沿着的护理差异累积起来造成差异的程度。我们 将全面评估整个筛查连续性，从使用的测试和筛查质量， 每年在约380万人的队列中接受随访护理和指南一致性治疗 在将近20年的时间里，凯萨医疗机构北方加州（KPNC）和凯萨医疗机构 南加州（KPSC）。我们将采用基于健康公平框架的混合方法， 检查：1）CRC筛查的接收和质量，包括异常时的随访; 2）筛查后 治疗和疾病结局，包括间隔CRC、5年生存率和年龄标准化发病率， 死亡率，总体和地点; 3）质量变化的原因和及时随访使用定性 访谈;和4）差异的相对贡献沿着筛选连续体的差异， 死亡率通过使用微观模拟建模。我们将在一个45-85岁的动态队列中进行研究。 2003-2019年期间，KPNC/KPSC中的男性和女性。KPNC和KPSC的成员反映了 就社会因素而言，加州服务地区的人们的特征。完整的 捕获所有筛选步骤和多样的、明确定义的人群，使研究策略能够跨越 在社会群体中筛选连续体。我们的分析将比较种族和民族群体， 在近20年的时间里，每个结果的种族分层。我们将采访患者-临床医生二人组 阐明质量、随访和结局变化的原因。我们还将使用MISCAN-Colon 微观模拟模型，以检查死亡率的差异在多大程度上归因于发现的差异， 在筛选过程的每一个步骤中。拟议的研究具有很大的潜力， 确定促进弱势种族和少数民族群体健康公平战略的优先次序 从而推进国家公共卫生优先事项。我们团队1.5年的高影响力合作， 我们的应用程序的设置和严谨性支持该领域的可行性和高潜力。

PROJECT SUMMARY/ABSTRACT: Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States and although the overall CRC mortality rate has been decreasing, disparities have persisted, particularly for Black and Native American people. CRC screening is highly effective and there is a welcome national attention on improving access to screening for groups that are socially disadvantaged. However, the benefits of screening depend on receiving both high-quality testing and timely follow-up care when abnormal. Thus, disparities may persist even when rates of participation in screening are similar across populations. Recently, the US Preventive Services Task Force highlighted a gap in the understanding of CRC disparities and the relative lack of interventions that have been shown to eliminate disparities by race and ethnicity. The goal of this application is to inform feasible and effective strategies for advancing health equity by elucidating the extent to which differences in care along the entire screening process cumulatively contribute to disparities. We will comprehensively evaluate the entire screening continuum from the tests used and screening quality to receipt of follow-up care and guideline-concordant treatment in a cohort of about 3.8 million people per year over a nearly 2-decade period in Kaiser Permanente Northern California (KPNC) and Kaiser Permanente Southern California (KPSC). We will use a mixed methods approach informed by health equity frameworks to examine: 1) the receipt and quality of screening for CRC, including follow-up when abnormal; 2) post-screening treatment and disease outcomes, including interval CRCs, 5-year survival, and age-standardized incidence and mortality, overall and by location; 3) the reasons for variations in quality and timely follow-up using qualitative interviews; and 4) the relative contributions of differences along the screening continuum to disparities in mortality by using microsimulation modeling. We will conduct our studies in a dynamic cohort of 45-85-year-old men and women in KPNC/KPSC during the 2003-2019 period. The members of KPNC and KPSC mirror the characteristics, in terms of social factors, of people in the regions served across California. The complete capture of all screening steps and diverse, well-defined populations enable studies of strategies across the screening continuum among social groups. Our analyses will compare the racial and ethnic groups and stratifications by race for each outcome over a nearly 2-decade period. We will interview patient-clinician dyads to elucidate reasons for variations in quality, follow-up, and outcome. We will also use the MISCAN-Colon microsimulation model to examine the extent to which disparities in mortality are attributable to differences found across each step in the screening continuum. The proposed research has a high potential to inform the prioritization of strategies for advancing health equity across disadvantaged racial and ethnic minority groups and thus advance a national public health priority. The 1½ decades of high-impact collaboration in our team, and the setting and rigor of our application support the feasibility and high potential for impact in the field.